Wednesday, October 31, 2007
First, to preface everything, I could not sleep last night. I don't know if it was because I was nervous, or because I was excited, or because I was anxious. All I know is that I woke up every half an hour pretty much all night. I reluctantly dragged myself out of bed at 5:30am so I could make it to the ED on time.
I was assigned to be with a nurse that was my age. She had graduated the same year I had for my first degree, yet she didn't lord over me, she treated me as an equal, for which I was grateful. It was weird that she has already had 3.5 years of nursing experience, and here I am a 2nd year accelerated nursing student, graduating this upcoming april at age ... well lets say 25+.
I have to say the very beginning of the shift was disappointing. Although the nurse was a great person to work with, we were assigned to work in the Ambulatory Care area. This is the area in the emergency department when the lowest acuity patients go. This is for the patient who is feeling unwell, who has abdominal pain, and who has a infected wound, etc. These patients are not going to die anytime soon, but can be also considered the "walking wounded". These patients generally didn't need much except to have blood drawn for labs, and not much treatment treatment besides IV fluids and a prescription for pain killers, antibiotics, etc. This was NOT what I had expected for my one and only day in the adult ED, as I really wanted to see a trauma or VSA, or something with higher acuity.
What started as a craptacular beginning quickly proceeded to change my mind once the nurses started working. I observed a lot of blood taking, and IV starting, for which all the nurses were more then willing to teach me the theory and what to look for once I am able to do those tasks*.
*IV starting and blood taking is an advanced skill not taught to nursing students in Ontario until during their practicum or even post-graduation. It is a designated act by a physician, although now it's mostly nurses initiating any peripheral IV.
Once the nurses felt comfortable with me, and I guess I showed them an adequate amount of knowledge, they then got me to do assessments on people, as well as start bringing in people from the waiting room! I felt like a pseudo-ED nurse.. I have only called people from a waiting room because I taught birth control, I have never done this in the ED! The patients thought I was an actual nurse (until corrected), which was cool, even though I introduced myself as a student nurse.
By the end of the day I was bringing in people, updating myself on the chart, asking a few questions to the RN's to make sure I was on the right track, and then assessing the patient by myself. I'm sure if they had an issue with what I had said, or if I hadn't answered any of their questions, they would have followed up with the patient. It felt nice that they were comfortable with me doing these assessments. Dont' get me wrong, I realize I am a student and I still have lots of learning to do, but it's nice to think that the RN's trusted me to do the right job.
Although I didn't end up observing any traumas or any high acuity patients, I enjoyed my day. I enjoyed the non-routine, and that the patients changed constantly. This is a great sign... perhaps now I can be more assured that ED nursing is for me.
Monday, October 29, 2007
Anyways, going to try to get SOME sleep. Want to be awake for tomorrow.
Friday, October 26, 2007
My supervisor, though, brought up the possibility the other day that due to unforeseen circumstances, my committee might not be able to read my thesis for a MONTH. What does this mean? It means that I might not be able to defend in early/mid December, the last possible time I could defend. You see, it seems simple, but in my department the exam committee needs a month to read it. Well, if my thesis committee is not going to approve my thesis, I wouldn't be able to submit my thesis to the committee until at least late November, which is too late for a defence in December, and it would get pushed until January.
I'm tired of this thesis. I've towed the line. I've done the work. Just let me defend and get this over with! I hate the idea that I'd have something overhead over the Winter break.
Thursday, October 25, 2007
Today was a very frustrating day in nursing class. My classmates and I are in an accelerated program: we have done 2+ years of university prior to entering this program, and are almost all mature students. For the most part, they are very open minded and not quick to judge. However, today was a different story, and it made me sad to think that these people are not willing to necessarily put oneself out there for the sake of the patient.
We were discussing abortion today in class. I'm not talking therapeutic abortion, where the patients choose to have a termination of pregnancy. What we were discussing was the medical term abortion, or in other words, a loss of a child in utero from all causes (both therapeutic as well as spontanious). One of my classmates had mentioned a clinical opportunity she had for which a medical resident asked questions about her patient's previous obstetrical history. This patient had a TPAL* of 1-0-2-0. She was shocked that the resident had brought up the abortion history, as it is a sensitive topic. I'm not 100% sure, but perhaps this resident had brought up the topic during an inopportune time or around the husband, which the student nurse thought was inappropriate. Anyway, after this, my classmates went on a bit of a rant about medical students and about residents and how 'socially stupid' they are.
** TPAL is used for obstetrical histories. It is an acronym for Term Premature births Abortions and Living children. Each number represents the amounts of each. A first time mom with a premature living baby would have a TPAL of 0-1-0-1.
I think her story and subsequent rant was in incredibly bad taste. This resident was asking RELEVANT patient history as the patient was about to give birth, which I quickly mentioned so I could stop the discussion about "inappropriate docs/med students". This quickly caused ripples and more adamant doctor-bashing discussion.. most opinions were pretty much thinking that I was wrong with agreeing that he needed to know the information, yet making the patient uncomfortable. However, I did quickly mention that I agree that perhaps the way that the resident was approaching the patient may not have been ideal, but as a medical professional, it was their responsibility to ask those questions, despite the possibility of awkwardness or uncomfortable-ness for the patient.
This goes for nursing as well. If I have a 13 year old patient in front of me complaining of abdominal pain, spotting, and frequent urination, I will ask the patient if she is pregnant. In addition, I will ask if she has been pregnant or had an abortion in the past. This is relevant history taking! Yes, this may make her a bit uncomfortable, but how are we to do what is right for our patient if we feel that asking the questions makes them squirm? In my mind, we're doing our patient a disservice by not asking these questions, and assuming that the patient would be uncomfortable. What if the other nursing student's patient had a therapeutic abortion, and was willing to talk about it? How are you supposed to know until you ask? Perhaps it wasn't a therapeutic abortion, and the patient had a history if placenta preva leading to a still birth at 19 weeks? This is VITAL information as it would determine more specific monitoring patterns as well as increased risk for both the mother and baby.
My other question is this: Why do nurses feel that it is their right to bash another professionals' practice? This does not just happen in my nursing class, this also happens on the nursing floor, where some nurses are very vocal on how "Dr so and so" can be such an idiot. Oh and don't worry, I have seen firsthand that nurses oftentimes eat their young, as well as criticize social workers, personal support workers, and pharmacists. Each profession is skilled in a different area. Why do some nurses feel they could accurately judge the professional practice of a doctor? Did they go to medical school? Unless the other professional is about to harm the patient, and their practice goes against everything the nurse learned about that particular condition, who are we to judge how the person approaches their work? Note it, and mention it to their supervisor, don't gossip to other nurses! As nurses we are taught to look at ourselves and try to remove our bias before we work with a patient. Perhaps we should do that with ourselves and with other professionals too!
Nurses are experts at nursing. Social workers are experts at their job. Why can't docs be experts at their job?
Tuesday, October 23, 2007
This week I had the opportunity to observe in the paediatric Emergency Department at the local children's hospital. Although paediatrics isn't my thing, I am more and more convinced that ER nursing is where I could fit. I like the system that is set up at this particular ER, for both adult and paediatrics (I even had the opportunity to observe in the Adult Emerg in the resuscitation room)
Today I was shown how lack of parenting is effecting the treatment of children, and how nurses sometimes have to be firm to get the point across.
This one child and his parents came into triage today. Apparently the child had had a series of respiratory infections, which eventually spread into a fairly serious case of otitis media; a fancy way of saying an ear infection. Anyway, the parents had taken him to the urgent care center here in town about 4 days ago, had been given the diagnosis, and had been given a prescription for the medication to treat it. The parents filled the prescription, and had also been giving the child some children's analgesics for the pain. Here is where the problem lies. The child is a fussy child, and the only child of the parents. He's 4 years old, and doesn't like hospitals. This is totally understandable for a sick child who maybe associates doctors or nurses with needles and pain. What got me was that because he was a fussy child at home, he had refused to take the prescription medication. Again, totally understandable, because he's a fussy child. Which brings me to the crux of this rant: The parents did not make him take the medication. Here is a child of 4 dictating what he can and cannot get medically! What sense does this make? What type of parents are these that don't even give medication needed to benefit the child? Who are the parents here? I would be more able to understand if they had some cultural or religious views on this particular medication and could not administer it for that reason, but to not give a child medication that he needs because the CHILD DID NOT FEEL LIKE TAKING IT? Come on!
So now the child has a worse ear infection, is in more pain, and the parents are at children's emergency because the ear was now leaking purulent drainage. Surprise surprise that the ear infection got worse. I had a hard time observing this because the child did NOT want his temperature taken as well, and the parents were trying to reason the kid into doing it. OK after teaching the kid what we're going to do, sometimes the parents need to take control of the child and do something for his/her benefit. Again, the parents did not step up. I was really tempted to hold his arm down to help the triage nurse, but alas, it is not my role to do that, it was the parents.
What happend? Why aren't parents stepping up to the plate? Don't they know that by their intent to not "hurt" or cause the child any discomfort, they are actually making the child worse?
I'm glad the ER nurse sat down with the parents after this and discussed the situation. I just hope they have learned a lesson from this. I sure have.
Tuesday, October 16, 2007
Today I had a reasonable day, with two general surgery kids- one with appendicitis with an abscess, and another with Crohns with a new ileostomy. An ileostomy is an opening from the small bowel to the abdomen, which is used instead of the rectum to expel stool. It is managed through special appliances so it doesn't smell and most people with ostomies can live normal lives. Typically, the higher up the bowel you go, the more watery the stool is. This kid had one temporarily so that any fistulas (a connection between bowels that is not supposed to be there) he had due to Crohns would heal. It'll be a few months before they do surgery again to put everything back together again.
Working with general surgery patients can be quite busy. When you arrive on shift you are to do vitals and 0800 meds. This means you need to set up secondary lines to IV's if need be, or in my case with paediatrics, work with buretrols ( a secondary chamber where you can put medications into it). Next, after flushing that line, you need to assess your patient to make sure that the medications aren't causing interactions, do a full systemic assessment, and then get your patient up and out of their bed for their first walk. This all has to be done before first break, and if you're not a student, you have 4-5 patients, not just 2. Also, because they are a surgical patient, they typically have a bunch of drains and tubes in every orifice, which of course need to be inspected, drained, and monitored. You also need to get rid of the drainage and record how much fluid was lost.
While I was in general surgery for my adult acute care rotation, I didn't realize how much work I actually did compare to my classmates. I thought they were all doing as much work as I was. Now that I'm on a general floor in paediatrics, where kids are sick but not all surgical, I realize how much extra work those drains/tubes end up being. I'm not trying to say that my classmates didn't work hard, I'm sure they did, but it seems to me that general surgery cases tend to take a lot more time. I had general medicine cases the last few weeks, and I had time to go on breaks, and time to read the chart. Today, even though I have worked with general surgery cases before, and they were fairly straightforward cases, I barely had a chance to eat lunch.
If I don't get into ER for my 4 month practicum next term, I said I would do Gen Surg. I'm not 100% sure I'll like it, but it'll definitely give me a large amount of skills and efficiency with complex cases, so applying to the ER will be more successful later on.
Monday, October 15, 2007
I found myself out of my element. I hate when kids cry. I mean, I really hate it. The reason I hate it that much is because of the uselessness I feel when working with them; I don’t know what is wrong with them, and I feel terrible that I cannot help them out. I also get incredibly frustrated because after some prolonged crying I feel as though nothing I have done has helped.
This week I had the opportunity to work with two little girls, one 3 years old, and one 23 months. The 3 year old had an undiagnosed mass midline and left lateral of her neck inferior to her hyoid bone. She was admitted because she had a fever, and a possible urinary tract infection along with the mass. Her foster mother had roomed in since Saturday with her, and had only left to go to the bathroom, and to have a shower (while the girl was with her foster father). The 23 month old had gotten caught in a conveyor at a dairy farm, and had a severe friction burn on her left lower arm. This friction burn required skin grafts, and unfortunately the first graft didn’t take- she had to have a second graft completed. This resulted in her having multiple dressings on her left arm, right arm, and left leg. Both girls had IVs as well as antibiotics to hang, which I feel more confident about giving.
I looked forward to the challenge of working with these two girls, as I had yet to work with anyone in paediatrics under the age of 11. They also seemed to have interesting medical cases, and their moms both were present, which made getting to know the girls a lot easier. The challenge for me, however, was when the 23 month old’s mom left. To give some backstory, this little girl had cried the entire beginning of the shift, a full 5 hours. At first, I thought the crying was because she was tired; her mom stated she hadn’t had a nap all day. We had gotten her to sleep for a bit, but because of protocols we had to check vitals every 5-10 minutes after giving morphine, so it ended up waking her up. Finally, at 8pm, we were able to get her to sleep. By this time I was exhausted; as you know I had spent earlier in the day with my brother for his knee surgery, and in total I was on my 18th hour of a 20 hour hospital day.
I dreaded going back and working with her the following day, as I knew the 23 month old girl would cry when she saw me. To my dismay she did, and also the 3 year old, generally a delight to work with, was acting up and crying too. Not only did I have 1 inconsolable crier, I now had two. Luckily, mom of the 3 year old took care of most of the crying, and helped out when I needed to do assessments. In the end, I spent over an hour and a half working with the 23-month-old, trying to console her after her mom left. I think she was finally comforted after she realized that I was not going to leave her alone.
I felt so helpless! Stop crying! Please stop! I think that I’ll have to black out for the first 5 years of my future children’s life, and let the hubby deal with it. I just can’t stand the crying.
Friday, October 12, 2007
Costs for universal health care are skyrocketing due to the ability to keep people alive longer, labour demands, increasing technology, and an aging population. With all this, the question of supplementary private healthcare has emerged as possibly being the solution to reduce the waiting times for surgeries and cancer treatment. In addition, with salaries being higher in the United States, it is not uncommon for Canadian-trained physicians and nurses to head to the US to get a better salary. This means less health care workers staying here in Canada, where they are also desperately needed, yet paid less.
I was recently in the USA and I met people who were working in the local mall. Being the health conscious person I am, I kept wondering to myself if they would have insurance through their jobs. In my experience, working retail doesn't give you a huge paycheck. What kind of healthcare insurance could a low-income worker expect to get? It seemed very odd to me that the person who I was talking to at the clothing shop wouldn't be able to go to a family physician without worrying about the cost. They aren't different then myself, yet I have no worries about paying for my last physical. I didn't know this, but I just looked it up and according to the U.S. Department of Health & Human Services, 43.6 million people in the United States, or 14.8% of the population, had no health insurance. Those people then delaying primary and preventative care, and then head to the emergency department when things get really bad, ultimately costing them more money, and taxpayer money as well. Compared to other countries, the US spends the most on health care, yet they still are unable to provide it to all their citizens.
I strongly believe that universal heath care is the way to go. As a future nurse, already I see people who would never be able to afford health care (or have jobs where they wouldn't receive private insurance) be able to get quality care because they need it. I think my ultimate fear as an upcoming nurse would be wanting to help someone but having them head home without my help because they couldn't afford it. Although universal health care does have its flaws, I don't think it should be up to your wallet size.
I have heard that the "greatest country is not the country who has the most stuff, or is the most rich. The greatest country is the one who takes the greatest care of their poor". That hits home and makes me think.
I would love to hear opinions of those who are against universal health care, and why.
Tuesday, October 9, 2007
Anyway, he's doing well, sleeping on the futon until after his appointment tomorrow. One good thing out of all of this is that his girlfriend is stepping up and taking care of him (something I didnt' think she'd do), so that means I dont' have to wake him up every 4 hours to take meds! YAY!
Well, my 20 hour day is catching up with me.'night.
I've been in the surgical area before, as a nursing student, and its interesting to see the differences between being a patient/family and being part of the medical/nursing team.
When I came to watch surgeries as a student, I frantically came in at 7am, got my green scrubs, and went to the pre-surgery area to introduce myself to my patient and hope that they would give me permission to watch. Then I went around with the nurses and they told me what they do to prep for the surgery. Watching the scrub nurse maintain sterility and knowing how many gadgets they need to prepare astounds me! Operating rooms, at least at this tertiary care center, are NOT AT ALL similar to ones on ER or Grey's anatomy. They are not large, spacious rooms with an observation area and homey covered walls. In fact, they are cramped because of the equipment, white and VERY bright so the surgeon can see what the heck is going on. Between the instruments needed for the surgery and the PEOPLE required to be there (especially at a teaching hospital), there isn't room for anyone, let alone the patient. There are the consultants whom oversee the surgery, then there are the senior residents, who mostly do the surgery, the junior residents who pop in and out depending on the severity and how many people are watching the floor upstairs, then there are the med student observers, the respiratory therapy students, the scrub and circulating nurses, nursing student observers, anesthetists, and their residents! Crazy eh! I enjoyed watching surgery, but honestly I dont' know how they can stand for 8 hours straight without walking anywhere. I don't see myself as the scrub nurse, although it was interesting to watch!
Anyways, its funny how being a family member of a patient makes the experience different. First, we had to get here at 6am to register. We waited in line for 30 minutes before the receptionist sent us up to the preoperative area. Then we get to the waiting room, my brother goes back by himself and they get him set up with a hospital gown, IV, and markings on his legs to tell the surgeons which leg to work on. Then after about 45 minutes of this, they call me in. It is now 7:40am. The nurse clinician explains post op stuff to both my bro and myself (at least I will remember it, my bro is like most non-medical people and has no clue what they are saying!), and then the circulating nurse also comes in to make sure the paperwork is done. The doc shows up briefly, in her scrubs, and then goes off to talk to another one of her patients and to prep her residents for the surgery. Finally, at 8:15am, (and a Code Red later), they ship him to the operating room. I am to wait in the waiting room for x number of hours until they get him to the post-surgical day unit, where I will take him home.
If I didn't' know the system, and how surgeries worked, I think I would be much more concerned and hesitant and feel really out of the loop. As a nursing student, I saw beforehand how the flow through surgery works... each person has their job with checks and balances to make sure things go smoothly, and the right area is worked on, and how long things can take. If I was not experienced with this stuff, it would be a very scary place to be. I would be taking everything the nurses and doctor said for granted (waiting times, etc), and waiting on edge until the doc or resident comes in to say everything went fine. I think it takes a lot of trust to sit here and wait to see if your loved one made it through surgery, and to trust the people with the scalpels that they know what they are doing. Personally, I feel weird sitting here when I have watched surgeries in the past. I want to watch this one! haha.
Although I have seen residents at work and know they are doing a great job and are overseen by the top surgeons in the area, I still know that they are learning and things can go wrong. I think sometimes the surgeons don't make it clear that they have a TEAM of residents and med students working on their patients, not just themselves. People put so much faith into that ONE person, the surgeon, and they don't realize that most likely the surgeon won't even be doing their surgery!
Anyways, I probably should do more then blogging if I'm to be on this extremely expensive internet. I'll update you on the progress of my bro as the day goes by. Did I mention that I also have to be at clinical placement today at 2pm, and it lasts until 10pm? Yes, that's right, 20 hours in the hospital today. woohoo!
Sunday, October 7, 2007
Whilst I am stuffing myself silly with... um... stuffing... I'm reminded of some things I am thankful for. In no particular order, I'm thankful for: stuffing, family, relationship, friends, stuffing, gravy, pumpkin pie, my cat Amber, and how about... the line of credit that I have been using to go shopping!
I have recently been howling at the comedy of Russell Peters. If you are from anywhere multicultural, you will LOVE his standup!
Friday, October 5, 2007
Once this admission happened and I had introduced myself to Dad, I left the room knowing I had to say something to the nurse that was supervising me. I pulled her aside and told her what my concerns were; that my patient was probably being discharged today yet he had mentioned these self-harmful things. I noted that this needed to be addressed somehow, and asked what we should do next. The staff nurse then told me that I needed to chart this, and that when the team came down to view his x-ray they needed to be told of the conversation, so they could decide about future treatment. I also told my clinical instructor, who helped me organize my thoughts and my observations about the interaction so I could chart it properly and effectively.
After charting this, I went back to visit my patient to chat and to spend time with him and his Dad. When Dad went to go get a drink downstairs, I seized my opportunity, played videogames with my patient, and tried to further develop our therapeutic relationship. I got more information out of him; his parents had divorced when he was young, and now his father was remarried and living in another town about 1.5hours away. He didn’t get to see his Dad much, but when he did, he enjoyed it a lot. He also mentioned that he and Mom moved around a lot. When asked where he had lived, he mentioned that he and his mom had lived in New Jersey, and that one day he was travelling into New York City when he saw the plane hit the World Trade Center. This struck me as odd: Two serious admissions in one day? Yet some of his facts checked out. I wondered, however, if his story was true, and how much of his comments were done in a self-attention manner. Overall though, these comments led to a picture of boy with some serious psychological assessment needed.Before I entered nursing I thought I had a pretty open minded view on mental health; that it was an important aspect of health and that sometimes it needs medical attention, just like an infection or a chronic cough. I never truly realized, though, how much sometimes people need help to cope with life. I also forget that sometimes people don't want to admit that there is a problem. At first the above patient's mom was VERY upset with the idea that her son needed some sort of psychological consult. I don't blame her. This is sort of saying that something about her son's mental health is not necessarily ok, and bringing in that stereotype that her son was 'crazy'. Even though I can openly say that he needs someone to talk to to work out these issues, I'm somewhat of a hypocrite because I would feel weird to talk to someone if I was in a similar situation. I'd probably even think it was unnecessary, and make myself feel stupid for seeking help. Although I am currently working towards changing that within myself, I can have a better appreciation of the hesitancy some people feel about going to a mental health professional.